Methods and devices for laparoscopic surgery

ABSTRACT

Two part laparoscopic tools and surgical methods using such tools are presented. The tools and methods enable use of multiple surgical tools each having wide tool heads to be used in a body cavity using a single wide trocar and one or more narrow incisions, thereby reducing surgical risk and enhancing patient comfort and shortening recovery time. Additional instruments for facilitating laparoscopic surgery are also presented.

RELATED APPLICATION/S

This application claims the benefit of priority under 35 USC 119(e) ofU.S. Provisional Patent Application No. 61/179,413 filed May 19, 2009,the contents of which are incorporated by reference as if fully setforth herein.

FIELD AND BACKGROUND OF THE INVENTION

The present invention, in some embodiments thereof, relates to devicesand methods for performing laparoscopic surgery.

Laparoscopic surgery (one form of minimally invasive surgery (MIS), alsoknown as band-aid surgery, keyhole surgery, or pinhole surgery) is amodern surgical technique with many advantages over traditional opensurgical methods. The first use of this approach in order to perform acholecystectomy was in 1987. Since that time, the procedure has gainedpopularity and is now regularly used in many different operations withinthe abdominal and pelvic cavities as well as for thoracoscopic andorthopedic surgery.

In existing laparoscopic methods, a variety of different instruments areused, including graspers, scissors, coagulation devices, harmonicscalpels, needle holders, cameras, suction devices and so on. Aplurality of such instruments may be required in a single procedure,with each instrument requiring its own trocar, which both acts as anentry port and facilitates manipulation of the devices within theabdominal cavity or other operative site. In general, laparoscopicoperations are usually performed by inserting 2-6 trocars (ports) intothe abdominal cavity, each through an incision in the skin.

The trocars usually range in size from 5 mm to 12 mm in diameter, eachserving as an introduction channel for one or more surgical tools.However, the use of trocars carries risks during both insertion andremoval. The risks include:

-   -   damage to blood vessels in the abdominal walls (particularly in        overweight    -   patients);    -   damage to fascial tissues;    -   extended and painful recovery period;    -   visible scarring;    -   relatively high cost;    -   time consuming; and    -   post-operative ventral hernia (POVH), particularly when the        larger trocars are used.

Most of the aforementioned risks and disadvantages are associated withthe relatively large size of the incision required for trocar insertion.

SUMMARY OF THE INVENTION

The present invention, in some embodiments thereof, relates to devicesand methods for performing laparoscopic surgery. More specifically, thepresent invention provides two-part laparoscopic tools which may beinserted into the body using fewer and/or smaller incisions than thoseused according to methods of prior art, and other tools for facilitatinglaparoscopic surgery. Embodiments of the invention significantly reducesurgical risks, simplify surgical procedures, and facilitate rapidpatient recovery.

The methods include performing laparoscopic interventions using one ormore multi-part instruments, wherein each instrument comprises a shaft(optionally with handle) and one or more operating tools (also called“operating heads” and “operating tool heads”) attachable to that shaft.The shafts have a cross-section considerably smaller than mostlaparoscopic tools of prior art and are designed for direct insertioninto the body cavity by puncture penetration or through a relativelysmall incision, rather than through a conventional laparoscopic port.The handles comprise a screw thread or other attaching mechanism attheir distal ends, suitable for attaching an operating head thereto.

In the following the term “wide trocar” refers to a trocar wide enoughto enable passage of an operating tool. A typical internal diameter of awide trocar would be 4 mm or larger, though that size is not to beconsidered limiting. In the following the term “narrow trocar” refers toa trocar only wide enough to enable passage of a shaft to which anoperating tool may be attached. A typical internal diameter of a “narrowtrocar” would be 3 mm or less, though that size should not be consideredlimiting.

Various embodiments presented herein enable providing a plurality ofoperating tools each connected to an individual shaft and able to beoperated independently, using only a single wide trocar, by introducinga plurality of operating tools into the body cavity through the widetrocar, and introducing shafts for those operating tools either throughnarrow trocars or by using a shaft (optionally with an insertedstiffener) to directly puncturing the cavity wall, thereby creatingopenings substantially similar in size to the diameter of the shaft.Such openings are considerably smaller than the opening required for awide trocar, and consequently are less damaging and provide fewercomplications, shortened recovery time and less bleeding and lessscarring.

Embodiments presented herein include methods for attaching an operatingtool to shaft and optionally also to a manipulating handle, including:

a) introducing a distal portion of a shaft into a body cavity, forexample by puncturing a wall of the cavity or by introducing the handlethrough the wall by means of a narrow trocar, introducing an operatingtool into the body cavity through a wide trocar, and connecting tool toshaft within the body cavity,

b) introducing a distal portion of a shaft into a body cavity, forexample by puncturing a wall of the cavity or by introducing the handlethrough the wall by means of a narrow trocar, extending the distal shaftportion towards and into a wide trocar, advancing the distal shaftportion through the wide trocar so that the distal shaft portion exitsthe body cavity through the wide trocar, attaching an operating tool tothat distal shaft portion while the distal shaft portion is outside thebody, and then withdrawing the shaft so that the attached operating toolis retracted into the body cavity where it can be used, and

c) attaching an operating tool to a shaft, the shaft optionally having asharp proximal end, introducing the shaft into a wide trocar, extendingit towards an inner portion of a body cavity wall, causing the shaft totraverse to body cavity wall so that the proximal shaft extends outsidethe body cavity, connecting a handle to the shaft portion which isexternal to the body cavity, and withdrawing the shaft far enough fromthe body so that the operating tool is drawn through the wide trocar andinto the body cavity, where it can be used.

The operating tools (also called “operating heads” herein) may be anysurgical tools, including (but not limited to) graspers, scissors,coagulation devices, harmonic scalpels, LigaSure, needle holders,ligatures, cameras and suction devices. The operating heads mayoptionally have shaft diameters similar to, or larger than, those ofconventional laparoscopic tools. According to some embodiments ofmethods of use, a plurality of these operating heads may be insertedinto the body (e.g. sequentially, through a single trocar port ofconventional design, or Gastro-Colonoscopically using a Natural OrificeTransluminal Endoscopic Surgery (NOTES) instrument) and may be matedwith and attached to their shafts within the body cavity. In alternativeembodiments one or more of such shafts may be inserted into the bodycavity, extended out of the body cavity (e.g. sequentially) through asingle trocar or a reduced number of trocars, attached to an operatinghead outside the body, and thence drawn back into the body cavitythrough the trocar. With either of these methods, the result is aplurality of narrow shafts penetrated into the body cavity throughpunctures or insertions which are smaller than typical trocar diameters,each shaft mated to an operating head, which may be any conventionalsurgical tool of normal diameter and capabilities. Additional operatingheads may be introduced into the body cavity and operating heads may beswitched and exchanged, all within the body cavity, during the course ofan operation. A plurality of surgical tools are thereby made availablefor manipulation and use within a body cavity, though a only a reducednumber of trocars (optionally only one) have been used.

Some embodiments of the present invention further comprise

-   -   tools for managing a plurality of operating heads within the        body cavity, comprising a plurality of connecting elements each        able to hold an operating head, and further comprising a        penetrating element operable to penetrate a body wall from        within the body cavity, and to extend beyond the body where it        may be grasped and immobilized from outside the body;    -   tools for inserting operating heads into the body cavity and/or        for removing operating heads from a body cavity, optionally        implemented as a sheath adaptable over a camera assembly        introduced into a body through a trocar;    -   tools for removing body tissues or other objects from the body        cavity during an intervention, comprising a sheath (optionally        adaptable over a camera assembly introduced into the body        through a trocar) and a rolled or folded bag which may be        introduced into the body cavity through the sheath, unrolled or        unfolded within the body cavity, filled with materials to be        extracted, and then withdrawn from the body through the trocar;    -   tools for stabilizing and/or immobilizing and/or positioning        body organs or other tissues during a surgical intervention        comprising a narrow shaft having a distal portion insertable        into the body cavity and connectable to an operating head, and a        stabilizing/positioning mechanism connected proximal portion of        the shaft outside the body and designed to stabilize the shaft        in a selected position; and    -   several grasper designs with detachable heads, some including a        head mechanism presenting advantages over head mechanisms known        to prior art.

It is noted embodiments of the present invention include (and are notlimited to) the above-listed components and embodiments used bothseparately and/or in concert, and further include additional componentsand embodiments as detailed below. It is further noted that the “wide”and “narrow” tools described in detail below may be used individually orin sets of several such tools used individually and/or in concert, andthat one or more “wide” tools may be used alone or in concert with oneor more “narrow” tools. It is further noted that the invention is notlimited to the specific exemplary uses described for the discloseddevices, and that the invention is also not limited to the specificallydescribed exemplary tool examples described as being used to perform thedisclosed methods.

Unless otherwise defined, all technical and/or scientific terms usedherein have the same meaning as commonly understood by one of ordinaryskill in the art to which the invention pertains. Although methods andmaterials similar or equivalent to those described herein can be used inthe practice or testing of embodiments of the invention, exemplarymethods and/or materials are described below. In case of conflict, thepatent specification, including definitions, will control. In addition,the materials, methods, and examples are illustrative only and are notintended to be necessarily limiting.

BRIEF DESCRIPTION OF THE DRAWINGS

Some embodiments of the invention are herein described, by way ofexample only, with reference to the accompanying drawings. With specificreference now to the drawings in detail, it is stressed that theparticulars shown are by way of example and for purposes of illustrativediscussion of embodiments of the invention. In this regard, thedescription taken with the drawings makes apparent to those skilled inthe art how embodiments of the invention may be practiced.

In the drawings:

FIGS. 1A and 1B are simplified schematics of a two-part laparoscopictool, according to an embodiment of the present invention;

FIGS. 2, 3, 4 and 5 are simplified schematics showing components of thetool shown in FIGS. 1A and 1B;

FIGS. 6A and 6B are simplified schematics showing a hollow grasper head;

FIGS. 6C, 6D and 6E show uses for the hollow grasper head shown in FIGS.6A and 6B, according to embodiments of the present invention;

FIG. 7 is a schematic of a laparoscopic tool with electrical functions,according to an embodiment of the present invention;

FIG. 8 is a narrow laparoscopic tool according to an embodiment of thepresent invention;

FIG. 9 is a grasper head showing opening and closing of the grasper,according to an embodiment of the present invention;

FIG. 10 shows several views of an additional construction of a grasperhead according to an embodiment of the present invention;

FIGS. 11A, 11B, 11C and 11D show details of connection between a shaftand a handle, according to an embodiment of the present invention;

FIG. 12 presents a immobilization device for surgery according to anembodiment of the present invention;

FIG. 13 presents a tool for manipulating operating heads within a bodycavity;

FIGS. 14 and 15 present examples of the use of the tool shown in FIG.13, according to an embodiment of the present invention;

FIGS. 16, 17 and 18 present several embodiments of a tool for removingmaterials from a body cavity, according to an embodiment of the presentinvention;

FIG. 19 presents a tool for organizing treatment heads within a bodycavity;

FIGS. 20, 21 and 22 present stages in the use of the tool shown in FIG.19, according to an embodiment of the present invention;

FIG. 23 presents a method for attaching a treatment head to a shaftaccording to an embodiment of the present invention;

FIGS. 24, 25, 26, 27, 28 and 29 present stages in a process forintroducing and using a surgical tool with a wide head in a body cavityusing only a small incision, according to an embodiment of the presentinvention;

FIG. 30 presents an optional enhancement to the method shown in FIGS.24-29, according to an embodiment of the present invention; and

FIGS. 31, 32, 33, 34, 35, 36, 37, 38 and 39 present aspects of asurgical procedure whereby a tool with wide operating head and narrowshaft may be introduced into a body cavity, according to an embodimentof the present invention.

DESCRIPTION OF SPECIFIC EMBODIMENTS OF THE INVENTION

The present invention, in some embodiments thereof, relates to devicesand methods for performing laparoscopic surgery. More specifically, thepresent invention provides two-part laparoscopic tools which may beinserted into the body using fewer and/or smaller incisions than thoseused according to methods of prior art, and other tools for facilitatinglaparoscopic surgery. Embodiments of the invention significantly reducesurgical risks, simplify surgical procedures, and facilitate rapidpatient recovery.

Before explaining at least one embodiment of the invention in detail, itis to be understood that the invention is not necessarily limited in itsapplication to the details of construction and the arrangement of thecomponents and/or methods set forth in the following description and/orillustrated in the drawings and/or the Examples. The invention iscapable of other embodiments or of being practiced or carried out invarious ways.

It is expected that during the life of a patent maturing from thisapplication many relevant laparoscopic tools will be developed and thescope of the terms “laparoscopic tool”, “operating tool” and “operatinghead” are intended to include all such new technologies a priori.

The terms “comprises”, “comprising”, “includes”, “including”, “having”and their conjugates mean “including but not limited to”.

The term “consisting of means “including and limited to”.

As used herein, the singular form “a”, “an” and “the” include pluralreferences unless the context clearly dictates otherwise. For example,the term “a compound” or “at least one compound” may include a pluralityof compounds, including mixtures thereof.

As used herein the term “method” refers to manners, means, techniquesand procedures for accomplishing a given task including, but not limitedto, those manners, means, techniques and procedures either known to, orreadily developed from known manners, means, techniques and proceduresby practitioners of the chemical, pharmacological, biological,biochemical and medical arts.

As used herein, the term “treating” includes abrogating, substantiallyinhibiting, slowing or reversing the progression of a condition,substantially ameliorating clinical or aesthetical symptoms of acondition or substantially preventing the appearance of clinical oraesthetical symptoms of a condition.

According to some embodiments of the invention there is presented amethod for inserting and removing surgical instruments during alaparoscopic procedure in the body cavity of a subject, comprising

-   -   inserting a surgical instrument (a grasper, for example)        constructed of two separate parts, a distal operating head        inserted into a body cavity through a conventional laparoscopic        port, by use of a Natural Orifice Transluminal Endoscopic        Surgery (NOTES) instrument, or by some similar method, and a        proximal shaft directly inserted into a body cavity through a        stab incision made in the wall of the body cavity;    -   connecting the two parts of the instrument;    -   use of the instrument within the body cavity    -   separation of the two parts following their use;    -   withdrawal of the shaft through its stab incision; and    -   withdrawing of the distal operating head through the port, NOTES        instrument, or similar device.

Connecting and separating distal and proximal portions of the device maybe performed with the assistance of a conventional grasper insertedthrough a trocar.

In some embodiments of the invention a surgical kit comprises a “widetool” and one or more “narrow tools”.

FIG. 1A presents an exemplary embodiment of a wide tool, comprising ashaft with a sharp distal end capable of penetrating a body wall, and adetachable head. FIG. 1B shows a wide tool with detachable headattached.

In some embodiments the shaft of the wide tool is inserted into a bodycavity through the cavity wall, and the distal head of the wide tool isinserted into the body cavity through a trocar and connected to the widetool shaft by manipulation by a grasper or other tool inserted through atrocar. In other embodiments the distal portion of the wide tool may becaused to traverse a portion of the body cavity, and exit the cavitythrough a trocar, where the wide tool head can be connected to the widetool shaft, which is then retracted into the body cavity. In yet otherembodiments the wide tool with head attached may be inserted into thebody cavity through a trocar.

Once the wide tool head is connected to the wide tool shaft andpositioned in the body cavity, the wide tool can be used as describedbelow to connect additional operating heads to additional tools havingshafts introduced (by puncture or very small incisions) into the bodycavity. These may be additional wide tools and/or “narrow tools” asdescribed below.

As may be seen in the exemplary embodiment shown in FIG. 1, the shaft ofthe wide tool may be implemented with a proximal handle shaped similarlyto a scissor, with one leg of the scissor attached to the outside of theshaft, and a second leg attached on an actuating rod or actuating cordpassing the length of the shaft and providing means for manipulating anoperating head when attached thereto by pulling or pushing on theactuating rod or cord and causing it to move backward or forward withrespect to the body of the shaft.

FIG. 2 shows a portion of a distal part of such a shaft, showing at “A”a passageway for such an actuating cord or rod, at “B” a connector forfluid (e.g. irrigation or suction), and at “C” a passageway for astiffening rod. FIG. 3 shows such a stiffening rod positioned alongsidethe shaft of a wide tool, and FIG. 4 shows the stiffening rod insertedtherein. Such a stiffening rod can be inserted in the shaft to stiffenand reinforce the shaft, for example when the shaft is caused topenetrate by force through a body wall or other tissue. The stiffeningrod can then be removed, leaving an empty passageway through whichfluids can be caused to flow (e.g. for suction or irrigation), or whichmay be used for other purposes such as passing objects therethrough.

FIG. 5 presents an additional embodiment where similar elements arepresented in a slightly different configuration. It is noted that thesmall passage, described above as used for passage of an actuating rodor cord, can be used for other purposes, such as for passage of anelectrical connection. Additional conduits within the shaft may besupplied as well.

The wide tool may be provided with a solid grasper head, or with agrasper head comprising hollow portions which can be used as conduitsfor fluids. Such a head, comprising a hollow, is shown in FIG. 6A, and adetail view of the hollow portion of such a head is shown in FIG. 6B.This hollow portion can be made continuous with the passage “C” shown inFIG. 2, or with another conduit in the shaft, to enable irrigation,suction, or some similar fluid-related activity. It is noted thatalthough a grasper head with a hollow portion is shown in the figures inthe context of tools with detachable heads as described above, graspersand similar surgical tools which comprise hollow portions and arecapable of implementing suction activity or irrigation activity inaddition to grasping may also be implemented in surgical instrumentswherein the grasper head is permanently attached to its shaft.

FIGS. 6C, 6D, and 6E show successive stages of fluid flow in the case ofsuction being applied at point “B” of FIG. 2.

Optionally the wide tool may comprise an electrical power connection,and portions of the shaft may be constructed of insulating materials ormay be covered by insulating materials, as appropriate. Electrical toolsmay be positioned at the operating head or may be incorporated in theshaft. An example is provided in FIG. 7, which presents a wide toolconfigured as a coagulator.

FIG. 8 presents a partial view of a “narrow tool”, one or more of whichare supplied together with at least one “wide tool” to form a kit, insome embodiments of the present invention. A narrow tool is similar to awide tool in that it comprises a shaft which comprises a distal endsharp enough to penetrate tissue, a separable operating head useful forperforming a useful function during a surgical procedure, and anattachment configuration (for example, screw threads) enabling to attachand the operating head to a distal portion of the shaft, and to detachit therefrom. In some embodiments the narrow tube comprises a conduitthrough which a wire and/or an activating rod or cord may be passed,which wire or rod or cord may be used to control or activate theoperating head or a portion thereof. Such a conduit is seen positionedin an upper portion of that part of a narrow tool shaft pictured in FIG.8.

It is an advantage of the narrow tool that it may be made extremelythin: in some embodiments the diameter of a narrow tool is between 1 and3 mm. (Note that these dimensions are given by way of example, and arenot to be considered limiting.) Thin shafts of such narrow dimensionscan be caused to penetrate through an abdominal wall (or into any otherbody cavity) with a minimum of damage to tissues through which theypass. In an exemplary method of use, a wide tool is introduced into abody cavity as described above, an operating head for a narrow tool isintroduced into a body cavity through a trocar, and the wide tool isused to grasp the detached narrow-tool head and to attach it to thenarrow tool shaft. In this manner one or many narrow tools can beintroduced into the body cavity and used within the cavity with onlyminimal damage to the cavity walls. Narrow tools so introduced aresimilar to standard laparoscopic tools and can be used by a surgeon withlittle or no special training.

In some embodiments the operating head is constructed of two parts, abase part connected to the shaft (e.g. to a wide tool shaft or to anarrow tool shaft), and a second moveable part connected to anactivating rod positioned in a conduit within the shaft. Moving theactivating rod forward and backward has the effect of moving themoveable head part with respect to the base head part, for exampleopening and closing a grasper as shown in FIG. 9.

In an alternative construction shown in FIG. 10, two moveable parts eachconnected to a common activating rod are also connected to a fixed partof a shaft. Forward and backward movement of the activating rod withrespect to the shaft has the effect of closing and opening the moveableportions of the grasper, as shown in the Figure.

A further alternative construction is presented in FIG. 11, which showsa configuration in which an external activating rod connects to anexternal portion of an operating head, and an internal activating rod,able to advance and retract within the external portion, connects to aninternal portion of the operating head. Advancing and retracting theinternal rod with respect to the external portion causes opening andclosing of the jaws of the grasper. Also of interest in the Figure: notethe form of the distal portion of the shaft in FIGS. 11A and 11D, whichdistal portion is pointed to facilitate penetration of tissues, butwhich also comprises screw threads enabling connection between shaft andhead. Note also the matching screw threads on outer and inner portionsof the operating head, as shown in FIGS. 11B and 11D.

Surgical Support Tools:

Physical Support Structure: In some embodiments of the invention thereis provided a support structure which enables to physically support orhold organs or parts of organs or other tissues in particular positions,to enable surgical work to proceed on those organs or tissues, or onorgans or tissues in their vicinity. FIG. 12 provides a view of anembodiment where a wide or more typically a narrow tool is used for thispurpose. The distal portion of the tube is made to penetrate into thebody cavity, the operating head is attached as described above, and theoperating head (in the form of a grasper or other tool) is made to seizeand hold a portion of the organ or tissues whose support orimmobilization is desired. As shown in the figure, an external supportdevice surrounding or otherwise connected to a proximal portion of thetool shaft, outside the body cavity, is adjustable and may be adjustedto maintain that proximal portion at a desired position and angle withrespect to the body. (In the exemplary embodiment shown in the figure, atripod or multi-legged shape with adjustable-length legs is used.)Fixing the position of the proximal portion, external to the body, alsofixes the position of the distal portion internal to the body, andthereby fixes also the position of the tissue or organ grasped by thehead.

Tool for removal of operating heads: FIGS. 13-15 present a tool forremoval of operating heads from within the body cavity. FIG. 13 showsthe head removal tool in the form of a sleeve formed to fit on a cameraor other visualization device introducible into a body cavity through atrocar. At the end of the operation or whenever desired, thevisualization device may be withdrawn from a trocar, a sleeve “E” addedto the device as shown in FIG. 13, and the device reinserted. In usesleeve E may be extended beyond the visualization device. A wide ornarrow tool is used to detach an operating head from a tool, and toposition it within or attach it to sleeve E as shown in FIG. 14. Thevisualization device together with sleeve E and the attached operatinghead can then be removed through the trocar as shown in FIG. 15.

Device for Extracting Tissues:

During the course of an operation it is often necessary to provide forremoving from a body cavity organs or tissues which have been excised,or to provide from removing devices introduced into the cavity duringthe operation. FIGS. 16-18 present a device for doing this.

As shown in FIG. 16, a sleeve is provided which is sized and shaped tobe adapted to a visualization device insertable into the body through atrocar or other port. An appropriately sized bag is rolled or folded andstored within the sleeve.

When deployment of the bag is desired, the bag may be unrolled orunfolded using a manipulation device (such as narrow or wide tool withgrasper head) present in the body cavity. The deployed removal bag isshown in FIG. 17.

In an alternative embodiment, the removal bag may be provided withflexible straps as shown in FIG. 18. The straps may be manipulated toopen the bag for use, and the bag may be removed from the body cavity bypulling on the straps, which extend beyond the trocar and may be graspedfrom outside the body of the patient.

Tool for Managing Operating Heads:

According to a further aspect of embodiments of the invention, there isprovided a tool for managing a plurality of operating heads within thebody of a patient.

As described above, operating heads may be inserted into a body cavity(e.g. through a trocar) and there may be attached to one or more toolshafts. In some cases it may be desired to have a plurality of operatingheads (e.g. a plurality of tools of different types) present within abody cavity, and to alternate use of various heads by attaching anddisconnecting them from one or more tool shafts, which shafts remain inplace and need not be removed from the cavity nor reinserted therein.

To facilitate this process a tool organizing device is provided, asshown in FIGS. 19-21.

The tool organizing device may be configured as a cartridge magazine, asa rack, as a shelf, as a set of hooks, or in any other convenientconfiguration.

FIG. 19 shows an exemplary tool rack (a tool organizer device or “headstorage tool” is configured as a set of connected hooks) is shownexternal to the body cavity.

In FIG. 20, the tool organizer device (head storage tool) has beeninserted into the body cavity, e.g through a trocar. To avoidmultiplying large body openings, if a single trocar has been installedand is used for passage of a visualization device into a body cavity,passing the tool organizer (or tool operating heads, or other objects)into the cavity may be done, for example, by removing a visualizationdevice from a trocar, passing the organizing device through the trocarinto the cavity, and then replacing the visualization device in thetrocar.

As shown in the Figure, the tool organizer comprises a penetrating pointlong enough and sharp enough so that if the device is grasped by a toolwithin the cavity the penetrating point may be caused to pass frominside the cavity to the outside of the body, where it may be graspedand held by a surgical tool. This has the effect of immobilizing thetool organizer as shown in FIG. 21.

A plurality of operating heads may then be stored in or on the deviceduring an operation, where they are accessible to being taken up by oneof the available manipulating tools (e.g. wide tool or narrow tool), yetare kept in order and out of the way of on-going surgical manipulations.This situation is presented in FIG. 22.

Attention is now drawn to FIG. 23 which shows a process whereby anoperating head may be attached to a penetrating tool while outside thebody, as was mentioned above. This procedure is convenient for attachingan operating head to a wide tool, which wide tool can then be used toattach operating heads to a plurality of narrow tools within the bodycavity. However, for convenience, the procedure shown in FIG. 23 can beused to attach heads to narrow tools as well.

As seen in the figure, a shaft is caused to penetrate into a body cavityin which a trocar or similar port has been inserted. The shaft is thendirected towards and through the trocar (a visualization device usingthe trocar may be temporarily removed from it for this purpose), andbecomes available outside the body, where the operating head may beattached. The shaft is then withdrawn through the trocar back into thebody cavity, where it may be used. A similar procedure can be utilizedto remove a head from a shaft before withdrawing the shaft from thebody.

Example of a Surgical Procedure Using Tools Described in this DocumentRemoval of an Appendix.

-   -   Insert standard trocar (e.g. trocar of 10 mm diameter) into a        body cavity wall, e.g. in the navel;    -   Insert a visualization modality (e.g. a camera), use it to        survey the body cavity, locate the infected appendix    -   Insert wide tool directly into lower belly    -   Temporarily remove visualization device, pass through the distal        portion of wide tool so that it extends beyond the trocar and is        outside the body.    -   Affix operating head to wide tool.    -   Withdraw wide tool through trocar into body cavity, replace        visualization device.    -   Introduce narrow tool into the lower belly above the pubis under        guidance of visualization device.    -   Remove visualization device from trocar, introduce operating        head (e.g. dissector) through trocar, restore visualization        device.    -   Use wide tool to grasp dissector head and affix it to narrow        tool shaft, under guidance of visualization tool    -   Remove visualization device from trocar, introduce tool        organizer, scissor tool, and a tool for immobilization of the        intestine.    -   Fix tool organizer in a place by holding with wide tool and        causing its penetrating point to penetrate the body wall to a        position outside the body, where it is grabbed by a standard        surgical device, thereby immobilizing it.    -   Mount spare operating heads on the organizing tool.    -   Proceed with the operation, cutting, cauterizing, etc. according        to standard surgical procedures as needed, using the various        tools held in readiness by the tool organizer, and changing        operating heads as needed. Appendix is disconnected from the        body, bleeding is cauterized and/or tied. Scissor head mounted        on one of the shafts and used to cut ligatures.    -   Visualization tool removed, sleeve containing tissue bag is        mounted on visualization device which is returned to place        through the trocar.    -   Bag is opened using narrow tool, appendix placed within bag, bag        and visualization device removed from body through trocar.        Visualization tool replaced in cavity.    -   Operation site is irrigated through hollow portion of wide tool.        Hemostasis checked.    -   Body cavity is irrigated, cleaned, inspected    -   Head removal tool mounted on visualization tool and used to        remove various operating tools, and (usually last) the tool        organizer    -   Narrow tool(s) withdrawn from body under observation by        visualization tool. Generally no stitching of the penetration        site is required.    -   Removal of visualization device, then of the trocar. Closing of        the opening through which the trocar was inserted.

Attention is now drawn to FIGS. 24-29 which show additional methods forproviding a plurality of operating tools with wide heads within a bodycavity having only a single wide opening.

FIG. 24 shows an operating tool with a wide head and a narrow shaftbeing inserted through a trocar into a body cavity. Note that in thefigure the wide operating-tool head is positioned outside the body, andthe narrow shaft is inserted through the trocar into that body. If FIG.25 the trocar, and the tool within it, is seen to be oriented so thatthe narrow shaft of the tool is aimed towards a selected portion of theouter wall of the body cavity.

FIG. 26 shows the shaft (which may have a sharp end) starting topuncture the cavity wall, moving from inside the body cavity towards theoutside. A continuation of the process is shown in FIG. 27, in which theshaft has penetrated the cavity wall, and can be grasped from outsidethe patient's body. The shaft can then be draw sufficiently far outsidethe patient's body so that the opposite end of the tool, with operatinghead attached, can be drawn through the trocar and into the body cavity.In the situation shown in FIG. 28, the operating head and distal portionof the tool are within the body cavity, and the tool's shaft is outsidethe body cavity. FIG. 29 shows a handle attached to the tool, which isnow read for surgical work within the body cavity. It the series offigures now described only one tool has been so inserted, but it s to beunderstood that a plurality of tools may be inserted into the bodycavity in this manner, each having only a narrow-diameter puncturepenetration of the body cavity wall and a wide operating tool head.

An optional additional embodiment is shown in FIG. 30, where a narrowtrocar, only slightly larger than the diameter of the tool shaft, ispositioned on the tool shaft prior to connection of handle to shaft. Thetrocar can be slid down the shaft and into the puncture hole around theshaft, where it serves to facilitate free motion of the shaft during thesurgical procedure and also serves to preserve gas pressure within thebody cavity if the body cavity is inflated, as is often the case duringsurgical procedures.

Attention is now drawn to FIGS. 31-39, which present aspects of asurgical procedure whereby a treatment tool with narrow shaft andrelatively wide treatment head can be introduced into a body cavity andmanipulated through a narrow incision.

FIG. 31 shows a surgical tool partially introduced through a trocar intoa body cavity, with shaft in the body cavity and operating head outsidethe cavity. A handle which comprises an internal stiffener having asharp point is shown inserted in the handle, outside the body. (Thestiffener is shown in dark color)

FIG. 32 shows the handle, with stiffener inserted, penetrating into thebody cavity wall. In FIG. 33 the stiffener has been removed, the handleremains penetrating the cavity wall. In FIG. 34, the shaft of the toolinserted through the trocar, and the handle inserted through the cavitywall are oriented towards each other, in FIG. 35 they approach eachother and in FIG. 36 they connect. Shaft and handle are provided with aconnecting mechanism such as matching screw threads or any otherattaching mechanism. A surgeon, manipulating both tools by theirportions positioned outside the body, can connect them.

Once handle and tool are connect, the handle can be partially retractedfrom the body, pulling the operating tool head through the trocar andinto the body cavity, as shown in FIG. 37. In FIG. 38 the tool is shownwith operating head within the body cavity and free to move, it's handlebeing outside the body where it can be manipulated by a surgeon. FIG. 39shows the tool approaching a surgical intervention site within the bodycavity.

To remove the tool, the surgeon can use the handle to insert theoperating head of the tool into the trocar, where he can grasp it fromoutside the body, and unscrew it or otherwise disconnect it from thehandle. Thereafter both the tool and the handle can be removed from thebody. The procedure can be used in introduce a plurality of such toolsthrough a single trocar, enabling a surgeon to employ a plurality oftools with wide heads without needing a plurality of wide openings inthe body cavity wall.

It is appreciated that certain features of the invention, which are, forclarity, described in the context of separate embodiments, may also beprovided in combination in a single embodiment. Conversely, variousfeatures of the invention, which are, for brevity, described in thecontext of a single embodiment, may also be provided separately or inany suitable subcombination or as suitable in any other describedembodiment of the invention. Certain features described in the contextof various embodiments are not to be considered essential features ofthose embodiments, unless the embodiment is inoperative without thoseelements.

Although the invention has been described in conjunction with specificembodiments thereof, it is evident that many alternatives, modificationsand variations will be apparent to those skilled in the art.Accordingly, it is intended to embrace all such alternatives,modifications and variations that fall within the spirit and broad scopeof the appended claims.

All publications, patents and patent applications mentioned in thisspecification are herein incorporated in their entirety by referenceinto the specification, to the same extent as if each individualpublication, patent or patent application was specifically andindividually indicated to be incorporated herein by reference. Inaddition, citation or identification of any reference in thisapplication shall not be construed as an admission that such referenceis available as prior art to the present invention. To the extent thatsection headings are used, they should not be construed as necessarilylimiting.

1) A laparoscopic tool which comprises a) A shaft with a sharp distalend suitable for penetrating tissue, which shaft comprises a conduitsized to permit passage of a fluid; b) a connection mechanism forconnecting said distal end of said shaft to an operating head; and c) anoperating head which comprises two jaws operable to clamp together tograsp an object, at least one which jaws comprises a hollow portion andan opening, wherein fluid flow through said opening into said hollow andthence into said conduit is enabled when said head is attached to saidshaft and suction is applied to a proximal end of said conduit. 2) Asurgical method which comprises a) Introducing a shaft into a bodycavity by puncturing a wall of that cavity with a distal end of saidshaft; b) Introducing an operating tool into said body cavity through atrocar; and c) Affixing said operating tool to said shaft within saidbody cavity; d) Using said operating tool connected to said shaft toperform a surgical procedure; e) Disconnecting said tool from saidshaft; f) Removing said tool from said cavity through said trocar; andg) Removing said shaft from said body cavity.
 3. A method of surgerywhich comprises a) passing an operating tool head through a trocar intoa body cavity; b) passing a shaft of a surgical tool through a wall of abody cavity through an incision not substantially larger than a diameterof said shaft and distant from said trocar, so that a proximal portionof said shaft is external to said cavity and a distal portion of saidshaft is internal to said cavity; c) connecting said operating tool headto said shaft; and d) using a portion of said shaft external to saidbody cavity to manipulate said operating tool head within said cavityduring a surgical procedure.
 4. The method of claim 3, furthercomprising attaching said head to said shaft while said head is withinsaid body cavity.
 5. The method of claim 3, further comprising passing adistal portion of said shaft from within said body cavity through saidtrocar until said distal portion emerges from said body cavity, andthere attaching said head to said shaft while said distal shaft portionis outside the body, then retracting said shaft to position saidattached head within said cavity.
 6. The method of claim 3, furthercomprising attaching said head to said shaft while both are outside thebody, extending said shaft into said body cavity through said trocar,causing said shaft to traverse a portion of said body cavity, reach aportion of a wall of said cavity distant from said trocar, and passthrough said cavity wall at said distant wall portion.